Table Of ContentMinimally Invasive Bariatric Surgery
Minimally Invasive
Bariatric Surgery
Edited by
Philip R. Schauer,
MD
Professor of Surgery,Lerner College of Medicine,Director,Advanced
Laparoscopic and Bariatric Surgery,Bariatric and Metabolic Institute,
The Cleveland Clinic,Cleveland,Ohio,USA
Bruce D. Schirmer,
MD
Stephen H.Watts Professor of Surgery,Department of Surgery,Health
Sciences Center,University of Virginia Health System,Charlottesville,
Virginia,USA
Stacy A. Brethauer,
MD
Staff Surgeon,Advanced Laparoscopic and Bariatric Surgery,
Department of Surgery,The Cleveland Clinic Foundation,
Cleveland,Ohio,USA
Philip R.Schauer,MD Bruce D.Schirmer,MD
Professor of Surgery Stephen H.Watts Professor of Surgery
Lerner College of Medicine Department of Surgery
Director Health Sciences Center
Advanced Laparoscopic and University of Virginia Health System
Bariatric Surgery Charlottesville,VA 22908
Bariatric and Metabolic Institute USA
The Cleveland Clinic Foundation
Cleveland,OH 44195
USA
Stacy A.Brethauer,MD
Staff Surgeon
Advanced Laparoscopic and Bariatric Surgery
Department of General Surgery
The Cleveland Clinic Foundation
Cleveland,OH
USA
The following figures are reprinted with the permission of The Cleveland Clinic Founda-
tion:Figures 3-1 through 3-10,19.1-1 through 19.1-3,20.1-2,20.1-3,20.1-5 through 20.1-9,
21.1-1 through 21.1-9,21.4-1 through 21.4-14,21.8-3A and B,21.8-5A and B,21.86A and
B,22.1-1 through 22.1-9,and 22.2-2 through 22.2-9.
Library of Congress Control Number:2006938046
ISBN:978-0-387-68058-3 e-ISBN:978-0-387-68062-0
Printed on acid-free paper.
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To my endearing wife Patsy and our jewels:
Daniel,Aaron,Teresa,and Isabella.
PRS
To my wife,Geri,who sacrificed her time with
me to allow its creation.
And to my two daughters,Kate Lynn and Liza,
the joys of my life.
Finally,I wish to thank the many patients who have
placed their trust and faith in me to help them with the
medical issues of their being overweight.
BDS
To my wife,Pam,for her incredible support and
encouragement,and to our beautiful children,
Katie,Anna,and Jacob.
SAB
Preface
Over the last decade,bariatric surgeons have witnessed more dramatic
advances in the field of bariatric surgery than in the previous 50 years of
this relatively young discipline.These changes have certainly been fueled
by the great obesity epidemic beginning in the 1970s,which created the
demand for effective treatment of severe obesity and its comorbidities.
The gradual development and standardization of safer, more effective,
and durable operations,such as Roux-en Y gastric bypass (RYGB),bil-
iopancreatic diversion,duodenal switch,and adjustable gastric banding
account for the first wave of advances over the last decade. More
recently, the advent of minimally invasive surgery in the mid-1990s
accounts for the second wave of major advances.
Fifteen years ago,fewer than 15,000 bariatric procedures (mostly ver-
tical banded gastroplasty) were performed each year in the United States,
and all were performed with a laparotomy requiring nearly a week of hos-
pitalization and six weeks of convalescence.Mortality rates exceeding 2%
and major morbidity exceeding 25% was the norm.It later became appar-
ent that the laparotomy itself accounted for much of the morbidity of
bariatric surgery. It contributed to major impairment in postoperative
cardiopulmonary function,which led to atelectasis,pneumonia,respira-
tory failure,heart failure,and lengthy stays in the intensive care unit for
a significant subset of patients.Furthermore,wound complications,includ-
ing infections,seromas,hernias,and dehisences were the norm rather than
the exception.Hernias were so common (20–25%) that they were often
considered the second stage of a bariatric procedure.
Today, more than 200,000 bariatric procedures are performed each
year in the United States and almost twice that figure worldwide.Nearly
all gastric banding procedures,an estimated 75% of RYGB procedures,
and even some BPD procedures are performed laparoscopically, indi-
cating that the laparoscopic approach has been widely adopted in
bariatric surgery.The dramatic reduction in postoperative pain,hospital
stays of only 1 to 3 days,recovery time of 2 to 3 weeks,incidence of inten-
sive care utilization to less than 5%,along with a great reduction in car-
diopulmonary complications and wound complications can be attributed
to the laparoscopic approach.Operative mortality of less than 1% is now
common and perhaps also attributable to laparoscopic surgery. Indeed,
bariatric surgery has become safer and more desirable because of laparo-
scopic surgery.
This textbook, Minimally Invasive Bariatric Surgery, is intended to
provide the reader with a comprehensive overview of the current status
vii
viii Preface
of bariatric surgery,emphasizing the now dominant role of laparoscopic
techniques. It is our intention to address issues of interest to not only
seasoned and novice bariatric surgeons,but all healthcare providers who
participate in the care of the bariatric patient.Specifically,we expect sur-
gical residents,fellows,allied health,and bariatric physicians to benefit
from this book.At the onset of this book,we invited contributing authors
whom we considered the most authoritative,coming up with a “Who’s
Who”list of bariatric surgeons.The reader will note among the authors
a high degree of clinical expertise and international diversity,as well as
diversity of thought.We have even included a chapter on the role of open
bariatric surgery to balance the enthusiasm of the editors for minimally
invasive surgery. Furthermore,we are thankful for our good fortune in
recruiting authors who have been in the forefront in developing and
teaching specific procedures. Although not intended to be an atlas of
bariatric surgery,this text does provide detailed illustrations and descrip-
tions of all the common procedures with technical pearls from the sur-
geons who introduced them to the world.
The benefits of laparoscopic surgery,however,must be balanced with
the significant training challenges posed by laparoscopic bariatric
surgery. Special emphasis on learning curves and training requirements
are found throughout this text.A chapter on training and credentialing
is included to update the reader on current guidelines.
To further enlighten the reader, we also have included chapters on
special issues and controversial subjects, including laparoscopic instru-
ments and visualization, bariatric equipment for the ward and clinic,
medical treatment of obesity,hand-assisted surgery,hernia management,
diabetes surgery, perioperative care, pregnancy and gynecologic issues,
and plastic surgery after weight loss.Chapter 24,“Risk-Benefit Analysis
of Laparoscopic Bariatric Procedures,” is particularly useful in that it
compares head-to-head the risks and benefits of all the major operations.
Finally,we do incorporate chapters that focus on new and futuristic oper-
ations, such as sleeve gastrectomy, gastric pacing, and endoluminal/
natural orifice surgery—perhaps the next wave of minimally invasive
surgery.
In the wake of the laparoscopic revolution of the 1990s, minimally
invasive approaches to nearly every abdominal procedure and many tho-
racic procedures have been devised. However, in reality, only a few
common procedures are now performed with a laparoscopic approach
as the standard (i.e.,>50%).Laparoscopic cholecystectomy,Nissen fun-
doplication,and bariatric procedures represent the major triumphs thus
far of the laparoscopic revolution. Perhaps, bariatric operations repre-
sent the best application of minimally invasive procedures because
avoidance of an extensive laparotomy in the high-risk bariatric popula-
tion provides the greatest relative benefit.We hope that you encounter
as much enjoyment reading Minimally Invasive Bariatric Surgery as we
have had writing it! Now,on to the next revolution in bariatric surgery!
Philip R.Schauer,MD
Bruce D.Schirmer,MD
Stacy A.Brethauer,MD
Acknowledgments
The editors would like to acknowledge and thank Margaret Burns,our
developmental editor, for her persistence and expertise in completing
this book;Tomasz Rogula,MD,PhD,for his many contributions to the
content and organization of the text; Joseph Pangrace, CMI, and the
medical illustration department at The Cleveland Clinic for creating
many of the superbly detailed illustrations included in the book;and our
editors at Springer,Paula Callaghan,Laura Gillan,and Beth Campbell,
for their guidance and support during the completion of this project.
Philip R.Schauer,MD
Bruce D.Schirmer,MD
Stacy A.Brethauer,MD
ix
Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Chapter 1
Pathophysiology of Obesity Comorbidity:The Effects of
Chronically Increased Intraabdominal Pressure . . . . . . . . . . . . . 1
Harvey J.Sugerman
Chapter 2
The Medical Management of Obesity . . . . . . . . . . . . . . . . . . . . . 7
Vicki March and Kim Pierce
Chapter 3
Evolution of Bariatric Minimally Invasive Surgery . . . . . . . . . . . 17
Iselin Austrheim-Smith,Stacy A.Brethauer,Tomasz Rogula,
and Bruce M.Wolfe
Chapter 4
Essential Characteristics of the Successful Bariatric Surgeon:
Skills,Knowledge,Advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
James C.Rosser,Jr.and Liza Eden Giammaria
Chapter 5
Bariatric Surgery Program Essentials . . . . . . . . . . . . . . . . . . . . . 31
Tomasz Rogula,Samer G.Mattar,Paul A.Thodiyil,and
Philip R.Schauer
Chapter 6
Essential Bariatric Equipment:Making Your Facility More
Accommodating to Bariatric Surgical Patients . . . . . . . . . . . . . . 37
William Gourash,Tomasz Rogula,and Philip R.Schauer
Chapter 7
Bariatric Surgery Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Stacy A.Brethauer and Philip R.Schauer
Chapter 8
Patient Selection,Preoperative Assessment,and Preparation . . . 57
Michael Tarnoff,Julie Kim,and Scott Shikora
xi
xii Contents
Chapter 9
The Evolving Role of the Psychologist . . . . . . . . . . . . . . . . . . . . 65
F. Merritt Ayad and Louis F.Martin
Chapter 10
Operating Room Positioning,Equipment,and Instrumentation
for Laparoscopic Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . 87
William Gourash,Ramesh C.Ramanathan,Giselle Hamad,
Sayeed Ikramuddin,and Philip R.Schauer
Chapter 11
Access to the Peritoneal Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Crystal T.Schlösser and Sayeed Ikramuddin
Chapter 12
Comparison of Open Versus Laparoscopic Obesity Surgery . . . . 113
Ninh T.Nguyen and Bruce M.Wolfe
Chapter 13
Anesthesia for Bariatric Surgery:What a Surgeon Needs
to Know . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Saraswathy Shekar
Chapter 14
Pneumoperitoneum in the Obese:Practical Concerns . . . . . . . . . 127
Ninh T.Nguyen and Bruce M.Wolfe
Chapter 15
Postoperative Assessment,Documentation,and Follow-Up
of Bariatric Roux-en-YSurgical Patients . . . . . . . . . . . . . . . . . . . 135
Edward C.Mun,Vivian M.Sanchez,and
Daniel B.Jones
Chapter 16
Bariatric Data Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Paul E.O’Brien,Mark Stephens,and John B. Dixon
Chapter 17
The Current Role of Open Bariatric Surgery . . . . . . . . . . . . . . . 149
Kenneth B.Jones,Jr.
Chapter 18
Technical Pearls of Laparoscopic Bariatric Surgery . . . . . . . . . . 157
Sayeed Ikramuddin
Chapter 19.1
Laparoscopic Vertical Banded Gastroplasty . . . . . . . . . . . . . . . . 165
J.K.Champion and Michael Williams
Chapter 19.2
Laparoscopic Sleeve Gastrectomy . . . . . . . . . . . . . . . . . . . . . . . . 173
Vadim Sherman,Stacy A. Brethauer,Bipan Chand,and
Philip R.Schauer
Chapter 20.1
Laparoscopic Adjustable Gastric Banding:Technique . . . . . . . . . 179
Paul E.O’Brien and John B.Dixon
Chapter 20.2
Laparoscopic Adjustable Gastric Banding:Outcomes . . . . . . . . . 189
John B.Dixon and Paul E.O’Brien
